Question: It is December 2022, and our office just realized evaluation and management (E/M) office coding no longer requires specific history or exam components. We are only using Eye Visit codes. Now we want to use the higher E/M level 4 and 5 codes. Where should we start?

Answer: Please review all the resources and information at aao.org/em. Since Jan. 1, 2021, the level of E/M for office and other outpatient settings are based on medical decision-making (MDM) or time. A medically relevant history and exam are required as determined by you, the physician.

The overall complexity level of MDM can be straightforward or of low, moderate or high complexity. To determine this overall level of MDM, first look at three components and determine which level of MDM complexity each of them would support. If at least two components indicate the same level of MDM, then that would determine the overall level of MDM. If the three components point to three different levels of MDM, then the middle one would determine the overall level of MDM.

Component 1: The number and/or complexity of problems addressed at the patient encounter
Component 2: The amount and/or complexity of data to be reviewed and analyzed
Component 3: The risk of complications and/or morbidity or mortality of patient management

Which E/M codes can you bill for the office visit? This is based on the overall level of MDM:

• Straightforward: Use codes 99202 or 99212 for new and established patients, respectively.
• Low complexity: 99203 or 99213
• Moderate complexity: 99204 or 99214
• High complexity: 99205 or 99215

Note: Effective Jan. 1, 2023 other places of service have the same documentation guidelines, including inpatient and emergency department services.
For more information, review Savvy Coder – E/M 2023-Starting Jan. 1, Streamlined Rules Apply Beyond the Office Setting.